Posted by: medicblog999 | December 21, 2009

Rescue Captains, Justins Blonde Hair and Engine 13

CoEMS

Following our lunch, which was another example of how working in an American Fire House is so much more different to on a UK ambulance station, i.e. everyone sitting down together and enjoying a wonderful home cooked meal (with HUGE portions!). It really did feel like sitting down for lunch with a big family. Conversation was flowing, music was coming in from the TV in the lounge area when all of a sudden everything stopped and we all looked over at the screen…..What’s this? Was Justin on the TV already??

No, but it was one hell of a likeness. Whatever music channel was on, there was some 70’s style music on. Willa noticed that one of the singers on screen had a startling resemblance to Justin, which just had to be recorded for Prosperity. Justin and Willa jumped into action, and I got the shot! What do you think?

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Justin blondie

Can it get any weirder?

The only thing that would complete the picture was if Justin only had blonde hair. In comes Janet to the rescue to lend Justin some of her luscious long blond hair. And…….Hey Presto!!

The laughter died down and everyone moved on to washing dishes and cleaning up. I wasn’t allowed to help with the washing so busied myself with wiping down the table. Once that was done, I popped out to the garage to see Ted and Chris who were busy editing, emailing, tweeting and uploading videos. Those two guys really didn’t stop during the whole time we were out!

It wasn’t long before the tones went off again, and everyone stops to listen to hear if it is the Engine or the Ladder going out. This time it was neither, instead it was for the Rescue Captain to go and assist with an unconscious patient.

Off he went in his SUV. I hadn’t really had much of a chance to see what his role was and how he fitted into this whole Fire Fighter/Paramedic thing so far, but I would change that before I went home from the Shift.

A couple more Fire Calls came in, all of which were false alarms or malfunctions in the alarm systems, but at least I got another ride out in Engine 13!

Then we had another medical call. This time to a collapse in the foyer of an office building just around the corner. We all took our seats again, Chris joining us to film the action whilst Ted stayed behind to get some shots of Engine 13 leaving the Station. As we arrived, Justin and I got out first whilst the other members of the crew followed behind. I made it my goal to actually have some part of these calls so I ensured that I at least grabbed the defib to carry in (there, you see, I was actually useful to have around). As we approached the patient, who was still sitting in a chair, you could tell that it wasn’t just another ‘nuisance call’. The lady, in her early 50’s, was pale and looked like she was just staring out into space. Justin quickly checked her radial pulse and called out

“No radial”

With that he, grabbed the patient’s upper body and I grabbed her legs, thighs and waistband.

“1, 2, 3 Lift!”

As soon as she was on the floor, I just grabbed hold of her feet and hoisted them into the air so that they were resting on my waist whilst I was standing up. To be honest, I didn’t know if that was what I should have been doing, but sometimes you can’t help but go into automatic pilot. If someone is so hypotensive that they lose their radial pulse, then those legs just need to go up!

Whether I should have done it or not, Justin seemed happy with what I was doing. She came round after about 20 seconds and tried to get back up. Everyone around her, Justin, I and the other 3 crew members of Engine 13 all tried to get her down on the ground. She was confused and obviously in need of hospital. After maybe 2 minutes the SFFD Ambulance arrived and took over care of the patient. Justin tidied up and stowed everything away back on the Engine and went to finish off his handover to the Ambulance Crew, and I got the opportunity to get one of my favourite pictures of my trip :

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The SFFD in action!

I don’t know if he realised it then, but I’m sure he did after he came over to the UK. The job he is doing on Engine 13 as the Paramedic is exactly the same as I do on my Rapid Response Car. Go out, get there first, stabilise the patient and have a good assessment ready where possible for the arrival of the crew. Obviously the only default is to transport to hospital or get a refusal form signed, but the basic role of the Engine Paramedic is not too different from mine on the car.

It wasn’t until afterwards when we were discussing the case with Ted and Chris that Justin said how weird it was that I did that with the legs, as he was just about to ask someone to do it, but I had already done it by the time he looked up. Proof yet again….Same patient, different country, and remember the basics!

The afternoon was interspersed with various other medical and alarm calls, but also a fair amount of down time where we did some filming and discussion pieces. I had the opportunity to discuss my thoughts on Engine responses with Justin also.

My thoughts, after going out on a few medical calls, where based solely on what I had witnessed, and may not have been the norm. Maybe I was just lucky that it was a fairly quiet day and the SFFD and other agencies ambulances weren’t being stretched too much, but all I could think was that if there was already an ambulance in that response area that will meet whatever response time target is already there, and there is no expected need to have a large volume of staff on scene, then why does the engine have to respond at the same time as the Ambulance?

Surely that is putting a lot of people at risk, both SFFD staff and the public who are either on the roads or pavements (sorry, sidewalks!) for a negligible benefit. Now, I would understand completely when there is not an ambulance close by to respond, and in fact, that is what I would love to see brought in to my own area.

As if to bring this point home, just before the evening meal at Station 13, the tones went off and again, it was for the Rescue Captain. This time however, it came through as resuscitation so Justin quickly asked the Captain, if I could come along with him, to which he replied that I could.

So I squeezed into the back of his SUV and off we went. It was a much farther distance than the engine would cover as there are far less of the Rescue Captains than there are ambulances or Engines. They are Paramedics who do not work on the Fire Engines at all. Their purpose it to arrive on scene and act in a supervisory capacity to ensure that everything is being done correctly and to provide assistance if required with some interventions that only they are allowed to perform, such as I.O cannulation. As we were travelling to this scene, he informed me that there would be two engines and an Ambulance on scene, as the first engine had only an EMT on board and not a paramedic, therefore a second engine was dispatched which had a paramedic as part of the crew.

We arrived on scene and were quickly informed that it was actually a heroin overdose pt that had gone into respiratory arrest. Naloxone had already been given before we got there and the patient was starting to come round.

I took a moment and stepped back a couple of paces and just counted … 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11!!  11 Members of the San Francisco Fire Department for 1 Patient !!!! 4 from each Engine, 2 from the Ambulance and 1 rescue Captain (oh and one UK paramedic in a green uniform standing there with his mouth hanging open!)

I understand the need to get a paramedic on scene for a life threatening emergency, I really do, but do you really need that many people on scene? This seems like the perfect type of job for Justin to trial his Rapid Response Model…Same call comes in. Justin responds as a lone paramedic in a fast response car with an ambulance following close by. 2 Vehicles, 3 members of staff.

Now I know what you are thinking – if the patient is in arrest, we would need more people in the back. Yes I completely agree, and that is where the benefit lies with having so many staff on scene – you can always pinch one to come in the back. However, if Justin was there in his RR Car, then he could travel in the back of the vehicle and lock his vehicle until the crew can drop him off afterwards. To be truthful, I think we have just gotten used to being alone in the back of an ambulance and trying to do the best CPR that you can whilst giving repeated doses of cardiac drugs etc! That doesn’t make it right though. I can’t think of a single medic who would not want at least two people in the back of an ambulance for a serious ‘working job’

Anyway, it’s something to think about. How many staff is too many on scene?

Once the patient had been transferred to hospital from the scene (in restraints, which is another thing that could never happen in the UK, The Rescue Captain drove me back to the Station 13, just in time to have me evening meal.

Yet again, another fantastic meal. Which reminds me that I never did get hold of one of the ‘San Francisco Fire Departments Fire House Cook Books’ to bring home!

I filled my belly, offered to do the dishes again, but again to no avail, then pinched a lift back to my hotel from Ted.

It had been a great day. I had a lot of thoughts whizzing around in my head and had thoroughly enjoyed seeing the dual role that Justin delivers day in and day out of his working career.

I seemed to be getting a little bit starry eyed about life in San Francisco, you always think the grass is greener over on the other side, but in reality, I know that there are all of the frustrations I have over in the UK, over in San Francisco too.

We were meant to be doing another ambulance shift in the morning, but that had been lost due to some miscommunication down the line. We could have still worked a shift, but it would have been some ungodly hours which would have impacted hugely on our following day and also the one chance that Justin may get to actually get home early and spend some time with his good lady and his beautiful children.

It gave us the chance to meet up a little later than normal the next day (yeah, a little sleep in), and to go and get some filming done in some of the more scenic places around the bay, then actually have a little free time in the afternoon.

Sounded good to me………

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Responses

  1. Mark, I've been following these posts avidly – but been rubbish at commenting. This time, however, I felt compelled. I was shocked to read about 11 emergency staff tending to one patient, and can't help but think that it's a huge waste of resources. I don't want to criticise without seeing or experiencing first hand, but still. On a resus in London, the “rules” are that it's supposed to be 1 FRU (single responder) and 2 ambulances – all in all 5 crew. I wish that that was really the case. It almost never happens – due usually to overstretched resources. On the other hand – if I had 11 on scene for one “simple” resus – I think it would be a case of too many cooks. However – if I've understood correctly – out of the 11, really only 4 were medically qualified to do anything (not including you of course!!). In which case – what did the other 7 do???? Waiting for all the further installments of your thoughts! Ben

  2. If SFFD had a paramedic on every engine, that would have reduced the response on the OD call from 11 to 7. A first-response unit (closest care), a transport unit, and a Rescue Captain that can provide unique specialty care is a logical response to this.Also remember that SFFD isn't just a medical agency, and that the units involved must be able to respond to fires, hazmat, extrications, and other manpower-intensive calls that can't be handled by only ambulances and fly cars as soon as they go available from the medical call.Further, the additional firefighters can help move the patient, which helps prevent the back injuries that end the careers of so many EMS personnel in the U.S.Lastly, all of SFFD's fire personnel are medically qualified. The fact that only 3 or 4 of the providers were ALS personnel doesn't mean that the BLS personnel have no medical capability. With BLS interventions comprising the bulk of Class I interventions for many life-threatening call types, the BLS providers are not only an important part of medical response, they're going to focus on the BLS components and not skimp on BLS while in a rush to start ALS procedures.

  3. It's not the overstaffing of simple (and not so simple) calls that scares me so much as the risk to the public of getting them there. Having a car and two five tonne ambulances going to a job such as an arrest on blue lights is scary enough in the UK, but sending two 30ish tonne fire engines too just seems like the risks outweigh the benefits. Enough ambulances crash every year, injuring crew, patients and bystanders – adding a fire engine to each job just increases the number of people who are going to be injured or killed, most likely disproportionately compared to the number who will be “saved”.Sounds to me like San Francisco, and the US EMS in general, really are ready for RRVs…

  4. I work in a slightly different EMS model from SFFD. We have Fire Dept. ALS Squads (non-transporting ALS units staffed with at least one Medic and an EMT, sometimes 2 Medics) in the busiest districts of our city. The Squads are dispatched with an ambulance to EMS calls in our district. This frees up the Engine in that district to be available for fire runs. For example our Squad makes 3,000 + runs a year, and our Engine close to 2,000. If there was no Squad then the Engine would make close to 5,000 runs a year. If we are first on scene we begin ALS care and then assist the ambulance crew (usually staffed with either 2 medics or a Medic and EMT) to package and load the pt.. If the ambo. is first on scene and don't need us then we go back in service (which happens pretty frequently). However, there are times when there are no ambulances immediately available and we may be on scene 15 or 20 mins. with a pt. before an ambulance arrives.On a cardiac arrest we also will frequently request an Engine or Ladder to assist with manpower (We remain on scene to work the patient for at least 30 mins. and only transport if we get ROSC so the manpower is needed to rotate people through who are doing compressions and to help move the pt. if we do transport).I really don't see sending an Engine/Fire apparatus on EMS runs as a waste of resources, because if we're not needed then the ambulance can have Dispatch disregard us. And if it's a situation where manpower is needed it's already there (or on the way)and doesn't need to be requested which is ultimately going to slow the pt's transport to definitive care (ER).

  5. It's not the overstaffing of simple (and not so simple) calls that scares me so much as the risk to the public of getting them there. Having a car and two five tonne ambulances going to a job such as an arrest on blue lights is scary enough in the UK, but sending two 30ish tonne fire engines too just seems like the risks outweigh the benefits. Enough ambulances crash every year, injuring crew, patients and bystanders – adding a fire engine to each job just increases the number of people who are going to be injured or killed, most likely disproportionately compared to the number who will be “saved”.Sounds to me like San Francisco, and the US EMS in general, really are ready for RRVs…

  6. Looking from a different angle, is there any truth to the rumor that each SFFD unit on the call counts as a separate dispatch, thereby increasing (or padding) the annual total of calls, thereby affecting the money the dept receives from the city?

  7. Hi Ben, As some of the commenters further down have stated, all of the people one scene were trained to at least EMT Basic level.I too had the feeling of too many cooks, but I would love to have some more hands on scene that what I get up here. Even LAS with 2 vehicles and a RR car sounds good to me! For us it is usually one vehicle. If a Rapid Response is close by they may get sent as well, but usually it is just the two staff, one Paramedic and one ECSW. Maybe somewhere in between the UK and SFFD would be just right?

  8. Thanks for the comment Ben.It was explained to me on a number of occassions, the need for the significant capability for Fire Response within the City, and for that, I completely agree with the numbers of bodies on the ground at any one time. I am also a great advocate for 'remembering the basics' and very definitely subscribe to the view of having hands on the patient by people trained to whatever level they have, to benefit the patient and hopefully create a good outcome.However, when someone like myself is standing back and looking in (when I am used to being on scene either by myself or with one other ECSW (Emergency care support worker), then to see 11 members of staff just blew my mind! Believe me, I would love to have more pairs of hands on a patient at times, but just how many do you really need for one patient?

  9. Hi Dave,I dont see Fire responses as a 'waste of resources' as such. If the resource is there and is not doing anything, then why not use it for medical benefit, however, there is still always the worry for me with sending too many people to a job, which is where your 'rescue squads' seem to fit in well!

  10. That was exactly my point Nick. I know that Justin (the happy medic) feels the same way too and would love to trial some sort of RR model in parts of the city.

  11. Errrrr…Thing I will let one of my U.S readers answer that one!That is how it works in my area with the Fire Brigade though. 2 Engines respond = 2 jobs.

  12. Hi CBEMT.As I was watching the patient being restrained and becoming aggressive with the fact that he was restrained, I mentioned to the Capt that I would not be able to do that in the UK. Once the patient was conscious and was capable of showing mental capacity, then he could just leave the scene.Where it becomes interesting/difficult is when I have a patient who doesnt have capacity and I assess him as needing care. We do have powers of removal in those cases under the Mental Capacity Act, and it does mention restraint in the patients best interest, but that is really dodgy ground and we dont have any straps etc to do that anyway. In those cases, it is time for our friendly neighbourhood police to come in and save the day!

  13. And several weeks ago at my service, two EMT-Bs managed a heroin OD/respiratory arrest on scene, and all the way to the hospital, just the two of them and their ambulance. And their patient is just as alive as the patient in SF that got 4 vehicles and 11 people.

    Ideal? Maybe not, it would have been much better for the patient to have been breathing for the 15 minute transport, despite receiving EXCELLENT manual ventilation.

    After the new year, our Basics will be getting the ability to administer Narcan intranasally. More efficient, and certainly safer, then sending 4 vehicles running around town.

    Can I ask why patients don’t get restrained in the UK? Someone who needs medical care but is combative for whatever reason still needs medical care. (Granted, I don’t have a restraint protocol, so we end up having to wing it, but it still gets done if necessary.)

  14. RRVs do exist in a number of U.S. EMS systems – I've worked them.They are common in the South Carolina Upstate – Greenville County, Spartanburg County, and Laurens County all use them, particularly in rural areas where there are not enough calls to justify placing an ambulance but where ALS response would otherwise be delayed.The problem is that the RRV is a one-trick pony. An ALS engine company can provide medical assists, fight fires, provide hazmat decontamination, handle carbon monoxide buildups in structures, and a host of other things a single medic cannot. If we are talking about medical calls only, the RRV/QRV unit makes sense. If you're talking about an “all hazards” capability, the RRV only has one use, so it's not as capable.As for driving safety, the weight of the vehicle doesn't matter, nor does the number of calls it runs. What matters is if the vehicle is properly maintained or not or if the driver drives it safely 100% of the time or not. In the systems where I formerly worked, EMS accidents (ambulances and QRVs) greatly outnumbered the fire engine accidents, and a couple of the EMS accidents killed either patients or civilian pedestrians. None of the FD accidents killed anyone.

  15. Why is it that we worry about “too many cooks” in the prehospital environment, but no one in hospital has the same issues. If the patient needs it, the hospital will crowd 8, 10, or more providers into a patients room to do CPR, push meds, intubate, ventilate, operate a monitor/defibrillator, have a physician who may never touch the patient directing, and have a nurse or unit clerk doing nothing other than scribing what was done and when.Why does that approach make perfect sense in hospital, but we worry about skimping and using the bare minimum – or less than the bare minimum – in the prehospital setting?

    • The problem is that over $1 million in apparatus and equipment, and 11 personnel, were sent hurtling through the streets- putting themselves and everyone on the road at risk- for an call that in all likelihood could have been easily handled by one ambulance, plus, MAYBE, the engine. No law that says you have to wake the guy up to the point that he’s fighting. Enough narcan to keep him breathing, and its off to the hospital. Let them deal with it.

      The first-due engine didn’t have a medic onboard. So what? The ambulance did. Unless the first-due forgot how to bag somebody, there was no reason they couldn’t wait for the bus. How far behind was it really? I’ll bet not enough time to make a difference.

  16. I can't speak for SFFD, but that happens in a lot of EMS-only systems in the U.S.In my fire/EMS system, we don't count “seperate dispatches”. We track two statistics, “Incidents” and “Responses”. The “Incident” statistic is a measure of just what it implies – how many incidents did we run in a given time period. The “Responses” statistic tracks how many units responded, regardless of whether the incident required a single unit or many.This is a fair, accurate, and ethical way to track your system's call volume. In EMS systems that count every response as a “Incident” it artificially inflates the number of incidents past the number that actually occur.In fire systems that must respond several units to a fire, hazmat, or other incident, just counting “Incidents” will under-report the actual number of units that are required for larger or more complex incidents. Reporting both statistics ensures that nothing is either under-reported or over-reported, thus accuracy and ethics are maintained.

  17. Type your reply…

  18. RRVs do exist in a number of U.S. EMS systems – I've worked them.They are common in the South Carolina Upstate – Greenville County, Spartanburg County, and Laurens County all use them, particularly in rural areas where there are not enough calls to justify placing an ambulance but where ALS response would otherwise be delayed.The problem is that the RRV is a one-trick pony. An ALS engine company can provide medical assists, fight fires, provide hazmat decontamination, handle carbon monoxide buildups in structures, and a host of other things a single medic cannot. If we are talking about medical calls only, the RRV/QRV unit makes sense. If you're talking about an “all hazards” capability, the RRV only has one use, so it's not as capable.As for driving safety, the weight of the vehicle doesn't matter, nor does the number of calls it runs. What matters is if the vehicle is properly maintained or not or if the driver drives it safely 100% of the time or not. In the systems where I formerly worked, EMS accidents (ambulances and QRVs) greatly outnumbered the fire engine accidents, and a couple of the EMS accidents killed either patients or civilian pedestrians. None of the FD accidents killed anyone.

  19. Why is it that we worry about “too many cooks” in the prehospital environment, but no one in hospital has the same issues. If the patient needs it, the hospital will crowd 8, 10, or more providers into a patients room to do CPR, push meds, intubate, ventilate, operate a monitor/defibrillator, have a physician who may never touch the patient directing, and have a nurse or unit clerk doing nothing other than scribing what was done and when.Why does that approach make perfect sense in hospital, but we worry about skimping and using the bare minimum – or less than the bare minimum – in the prehospital setting?

  20. I can't speak for SFFD, but that happens in a lot of EMS-only systems in the U.S.In my fire/EMS system, we don't count “seperate dispatches”. We track two statistics, “Incidents” and “Responses”. The “Incident” statistic is a measure of just what it implies – how many incidents did we run in a given time period. The “Responses” statistic tracks how many units responded, regardless of whether the incident required a single unit or many.This is a fair, accurate, and ethical way to track your system's call volume. In EMS systems that count every response as a “Incident” it artificially inflates the number of incidents past the number that actually occur.In fire systems that must respond several units to a fire, hazmat, or other incident, just counting “Incidents” will under-report the actual number of units that are required for larger or more complex incidents. Reporting both statistics ensures that nothing is either under-reported or over-reported, thus accuracy and ethics are maintained.

  21. Type your reply…

  22. Hi Ben, thanks for all of your comments and input.Firstly, I hope you don't think that I am 'bashing' the way it is done in SFFD, quite the contrary, I am incredibly honoured that I got the opportunity to work with them.But, the one thing that makes what Justin and I are doing so valuable is that we are looking at things with completely different eyes from those that normally see things. These posts are about my impressions and thoughts as they happened when I was there. As you can imagine, going from working alone to working a job with so many other responders seemed a tad OTT, but that is only because I am used to so much less.I would love to have more trained personnel to assist me in some ofthe jobs that I go to, but as I am sure you will agree, the times that you really need numbers on a scene are very few and far between. You also ask the question, how this is different from being in a hospital?The difference is space and practicality. Yes, it's great to had a trauma team waiting for a patient, but could they be effective in a small residential kitchen, or more likely when there is a patient trapped behind the door of a bathroom?The goal we should be striving for is an 'appropriate response' for the emergency at hand. And that, for the majority of cases will be far less than 11 staff.

  23. CBEMT, you're still framing this as if it's an EMS-only discussion, when it clearly is not. The flip side of engine company response is that a RRV/QRV can't run a fire, hazmat, or other non-EMS call 30 seconds after they clear, and the engine company can. The purchase cost of the delivery vehicle isn't pertinent – that vehicle costs the same whether it is running EMS calls or not. The replacement costs, especially for urban departments are age and technology-dependent, not mileage-dependent. The maintenance costs are negligible as a percentage of overall system costs, and some are proportionally less, as the fire apparatus are engineered to much stronger standards than are ambulances that are simply afterthoughts on a commercial medium-duty truck – or light-duty van. Further, with CPR and defibrillation (engine company skills) being the most two important interventions (the primary Class I interventions, check with ACLS or the Utstein criteria) on cardiac arrest calls, it doesn't make sense to have this resource sit in the station because the ambulance might be there a few seconds later (usually minutes, not seconds) when time to CPR and time to the first defib are the most important Utstein survivability factors.I didn't suggest that fire apparatus are 100% safe, but they have far fewer accidents than do ambulances, because their drivers tend to be specialists in driving those vehicles. The fatality rate for fire apparatus accidents is very low – check out the statistics that the U.S. Fire Administration publishes every year. As for driver error, everything you stated for fire apparatus goes for ambulances, with much higher overall serious accident rates, and for the same reason, with the added problem of lower driver training and experience requirements in most places.The other benefits of an EMS engine company (especially trained manpower) have already been noted.

  24. CBEMT, The cost of the apparatus isn't “a problem”, let alone “the problem”. You persist in making this an EMS-only discussion when it was not. Once again, an all-ALS engine company fire department would have eliminated the first-due, non-ALS engine and cut the response to three vehicles. The timing for this call is speculative, and if SFFD's dispatch protocols require an ALS engine dispatch if there's not another ALS unit closer, then the two-engine response for a potential unconscious/unresponsive patient is appropriate. EMS isn't just about a ride to the hospital, nor is it limited to the type of vehicle in which the providers ride to work.Claiming that a response model is “a problem” is simply not accurate just because you disagree with that response model.

  25. It's still using a $350,000 piece of apparatus to deliver ONE person to the scene, usually mere seconds before the unit capable of actually dealing with the problem (transport) does.Weight DOES matter. The weight affects performance, handling, braking, and how fast this very expensive paramedic-deliverer vehicle (70-80% of the time, anyway) wears out or breaks down, and the taxpayers are forced to buy a replacement/pay for repairs etc. And if you're suggesting that the drivers of such apparatus operate safely 100% of time, you haven't been paying attention. Yes, yes, I'm sure everyone you work with is the perfect driver. Meanwhile, in reality, fire apparatus collisions occur all the time, often fatal, often due to operator error, excessive speed, etc.

  26. The last one that really needed both serious treatment AND restraint was an extremely intoxicated young man who had also probably hit his head during a fall, and had been swinging at police prior to our arrival. They'd handcuffed him, but with the possibility of the combativeness being secondary to his head injury, he needed to be collared and boarded. The police had him cuffed, and let me tell you- getting him uncuffed, flipped over to supine, restrained, and boarded was quite an adventure! But it had to be done.

  27. CBEMT, you're still framing this as if it's an EMS-only discussion, when it clearly is not. The flip side of engine company response is that a RRV/QRV can't run a fire, hazmat, or other non-EMS call 30 seconds after they clear, and the engine company can. The purchase cost of the delivery vehicle isn't pertinent – that vehicle costs the same whether it is running EMS calls or not. The replacement costs, especially for urban departments are age and technology-dependent, not mileage-dependent. The maintenance costs are negligible as a percentage of overall system costs, and some are proportionally less, as the fire apparatus are engineered to much stronger standards than are ambulances that are simply afterthoughts on a commercial medium-duty truck – or light-duty van. Further, with CPR and defibrillation (engine company skills) being the most two important interventions (the primary Class I interventions, check with ACLS or the Utstein criteria) on cardiac arrest calls, it doesn't make sense to have this resource sit in the station because the ambulance might be there a few seconds later (usually minutes, not seconds) when time to CPR and time to the first defib are the most important Utstein survivability factors.I didn't suggest that fire apparatus are 100% safe, but they have far fewer accidents than do ambulances, because their drivers tend to be specialists in driving those vehicles. The fatality rate for fire apparatus accidents is very low – check out the statistics that the U.S. Fire Administration publishes every year. As for driver error, everything you stated for fire apparatus goes for ambulances, with much higher overall serious accident rates, and for the same reason, with the added problem of lower driver training and experience requirements in most places.The other benefits of an EMS engine company (especially trained manpower) have already been noted.

  28. CBEMT, The cost of the apparatus isn't “a problem”, let alone “the problem”. You persist in making this an EMS-only discussion when it was not. Once again, an all-ALS engine company fire department would have eliminated the first-due, non-ALS engine and cut the response to three vehicles. The timing for this call is speculative, and if SFFD's dispatch protocols require an ALS engine dispatch if there's not another ALS unit closer, then the two-engine response for a potential unconscious/unresponsive patient is appropriate. EMS isn't just about a ride to the hospital, nor is it limited to the type of vehicle in which the providers ride to work.Claiming that a response model is “a problem” is simply not accurate just because you disagree with that response model.

  29. No, there is no connection between the number of responses and the amount of money the Dept receives from the City. The current Fire and EMS budget is 3% of the City budget with revenue from transport going to the general fund. If we ran 30,000 or 120,000 that would likely never increase, but would surely decrease.

  30. Not all SFFD line personnel are required to be EMT trained. A fair number were hired before it was a requirement, but each apparatus has a position that can only be filled by an EMT, so at least one person is. It can be frstrating when 2 engines respond, the nearest BLS and the second ALS, simply so an EMT and Medic can arrive on the scene, but unless someone is willing to find the money to make all the engines ALS, we're stuck with what we have.California law requires 2 Paramedics respond to each emergency. They don't explain what that means, however, so one on an ambulance and another in a car would meet the requirement. then again if you pull me off the engine and place me on a car, they will still send the closest EMT resource, an engine. It is all based on the flawed BLS before ALS system.When we have 2 of the 10 busiest engines in the country less than 3 miles from one another though, something has to give. And each of those engines have had multiple greater alarm fires in the last month.

  31. So, how big of a fight is OK in order to get a violent patient in a c-collar and on a spineboard? If the patient is violent and is not paralyzed, that's fairly good prima facie evidence that there is no spinal injury with serious orthopedic or neurological compromise. In that case, wouldn't it be more appropriate to leave the patient restrained, treat the potential medical problem, and transport rather than a prolonged fight to get the patient on a collar and board? That can't be good for a patient that has either a spinal injury or a head injury with increased ICP.As to the orignal comment, just because an all-BLS crew can manage an OD doesn't make that the ideal way to do it.

  32. No, there is no connection between the number of responses and the amount of money the Dept receives from the City. The current Fire and EMS budget is 3% of the City budget with revenue from transport going to the general fund. If we ran 30,000 or 120,000 that would likely never increase, but would surely decrease.

  33. Not all SFFD line personnel are required to be EMT trained. A fair number were hired before it was a requirement, but each apparatus has a position that can only be filled by an EMT, so at least one person is. It can be frstrating when 2 engines respond, the nearest BLS and the second ALS, simply so an EMT and Medic can arrive on the scene, but unless someone is willing to find the money to make all the engines ALS, we're stuck with what we have.California law requires 2 Paramedics respond to each emergency. They don't explain what that means, however, so one on an ambulance and another in a car would meet the requirement. then again if you pull me off the engine and place me on a car, they will still send the closest EMT resource, an engine. It is all based on the flawed BLS before ALS system.When we have 2 of the 10 busiest engines in the country less than 3 miles from one another though, something has to give. And each of those engines have had multiple greater alarm fires in the last month.

  34. So, how big of a fight is OK in order to get a violent patient in a c-collar and on a spineboard? If the patient is violent and is not paralyzed, that's fairly good prima facie evidence that there is no spinal injury with serious orthopedic or neurological compromise. In that case, wouldn't it be more appropriate to leave the patient restrained, treat the potential medical problem, and transport rather than a prolonged fight to get the patient on a collar and board? That can't be good for a patient that has either a spinal injury or a head injury with increased ICP.As to the orignal comment, just because an all-BLS crew can manage an OD doesn't make that the ideal way to do it.

  35. If SFFD can spare two engines just to chauffeur and EMT and a paramedic, then perhaps they need fewer engines and more ambulances. If two engines are tied up on one medical call, then who is covering their first due areas for fire calls? It seems like an incredible waste of time, effort, and money without discernible benefit to the patient. As to why hospitals have so many people in trauma rooms, it's because the people are just hanging around. Not the same situation as in the field. Nor is there any discernible benefit to the patient in having more people as more people doesn't necessarily translate into better care. Around these parts, the better trauma centers strictly limit the number of people in a resuscitation. They've found it works better that way.

  36. SFFD can't “spare” the engines to the point that they can do without any of them. We're talking about a city that still has institutional memories of the entire city being destroyed by the 1906 earthquake and fire and receiving heavy damage that overtaxed their entire force in the 1989 Loma Prieta earthquake. S.F. also has standards of cover for engine response times that are designed to protect the many old wooden structures in the city, many of them multi-occupancy residential. On the call in question, if there is a nearby fire, the BLS engine can be sent to it as soon as either the ALS engine or the BLS engine arrive. The issue isn't more ambulances necessarily translating into better care, it's a fire department that has to be ready for a disastrous, city-ruining event every day, even if the event doesn't occur for years.As I've replied to others, this isn't just an EMS issue, even though some of the people who have responded are EMS-only providers. It is an all-hazards issue.And – there are discernible benefits to having extra manpower on medical calls. The extra lifting assistance that helps prevent back injuries to the ambulance personnel is one, Having a big truck as a traffic blocker increases scene safety, which is another discernible benefit. Having help carrying equipment up four or five flights of stairs is a discernible benefit. Having engine and ambulance crews routinely work together on small incidents to practice their teamwork for larger and/or more complex incidents is a discernible benefit. Having extra people to provide a privacy screen with a salvage cover is a discernible benefit. There are others.The call in question EMD couldn't rule out a possible cardiac arrest. The engine companies were the closest responders. CPR done correctly is physically exhausting. If I were the patient, I'd like having a manpower reserve to maintain good CPR with fresh people for as long as the resuscitation lasted…another discernible benefit.I'm curious why you would think that not having an immediate pool of fresh manpower to do CPR isn't “better care”???

  37. Ah, here we go. I dared question the Big Red Machine, so now everything I say will be questioned. The patient was boarded and collared because I don't get to make the decision not to. He was on an upper floor, and being combative he was getting carried out anyway. If I'm already strapping him down for that, it doesn't take much to immobilize c-spine as well, with the added bonus of keeping him from that much more still for the trip down the stairs. I already said BLSing the OD wasn't ideal. But the funny thing is, the patient is still alive due to excellent airway management. Just as alive as the patient that got a $1 million response.

  38. CBEMT, that's not the case at all. In my system, we have the option to avoid spinal packaging with violent patients, particularly when the fight to package them might be worse for their condition than carrying them downstairs in an evacuation triangle or on a stair chair.This has nothing to do with “the big red machine”, it's about what's best for the patient. Forced spinal packaging protocols that don't leave any discretion for what's actually best for the patient are not good protocols. There are chemical sedation protocols, RSI, and several other options that don't require a fight to get the patient packaged.If you don't have the discretion and the fight is inevitible, isn't it better to overwhelm the patient with lots of responders to minimize the time spent fighting prior to packaging the patient?That's usually safer for both the responders and the patient.And… this is the internet, and anything you post is subject to being questioned.

  39. SFFD can't “spare” the engines to the point that they can do without any of them. We're talking about a city that still has institutional memories of the entire city being destroyed by the 1906 earthquake and fire and receiving heavy damage that overtaxed their entire force in the 1989 Loma Prieta earthquake. S.F. also has standards of cover for engine response times that are designed to protect the many old wooden structures in the city, many of them multi-occupancy residential. On the call in question, if there is a nearby fire, the BLS engine can be sent to it as soon as either the ALS engine or the BLS engine arrive. The issue isn't more ambulances necessarily translating into better care, it's a fire department that has to be ready for a disastrous, city-ruining event every day, even if the event doesn't occur for years.As I've replied to others, this isn't just an EMS issue, even though some of the people who have responded are EMS-only providers. It is an all-hazards issue.And – there are discernible benefits to having extra manpower on medical calls. The extra lifting assistance that helps prevent back injuries to the ambulance personnel is one, Having a big truck as a traffic blocker increases scene safety, which is another discernible benefit. Having help carrying equipment up four or five flights of stairs is a discernible benefit. Having engine and ambulance crews routinely work together on small incidents to practice their teamwork for larger and/or more complex incidents is a discernible benefit. Having extra people to provide a privacy screen with a salvage cover is a discernible benefit. There are others.The call in question EMD couldn't rule out a possible cardiac arrest. The engine companies were the closest responders. CPR done correctly is physically exhausting. If I were the patient, I'd like having a manpower reserve to maintain good CPR with fresh people for as long as the resuscitation lasted…another discernible benefit.I'm curious why you would think that not having an immediate pool of fresh manpower to do CPR isn't “better care”???

  40. Ah, here we go. I dared question the Big Red Machine, so now everything I say will be questioned. The patient was boarded and collared because I don't get to make the decision not to. He was on an upper floor, and being combative he was getting carried out anyway. If I'm already strapping him down for that, it doesn't take much to immobilize c-spine as well, with the added bonus of keeping him from that much more still for the trip down the stairs. I already said BLSing the OD wasn't ideal. But the funny thing is, the patient is still alive due to excellent airway management. Just as alive as the patient that got a $1 million response.

  41. CBEMT, that's not the case at all. In my system, we have the option to avoid spinal packaging with violent patients, particularly when the fight to package them might be worse for their condition than carrying them downstairs in an evacuation triangle or on a stair chair.This has nothing to do with “the big red machine”, it's about what's best for the patient. Forced spinal packaging protocols that don't leave any discretion for what's actually best for the patient are not good protocols. There are chemical sedation protocols, RSI, and several other options that don't require a fight to get the patient packaged.If you don't have the discretion and the fight is inevitible, isn't it better to overwhelm the patient with lots of responders to minimize the time spent fighting prior to packaging the patient?That's usually safer for both the responders and the patient.And… this is the internet, and anything you post is subject to being questioned.

  42. I agree that my protocols don't leave me with good options. Those decisions are made at the state level. In any event, he was not going to be coming out on anything that didn't allow for every extremity to be strapped down. Anything he could move, he moved, including his head. Stairchair was not an option due to the degree of resistance. A Reeves might have worked, but we don't have one. No RSI, and having never done it before I'd be hesitant to chemically sedate with what I have given the level of intoxication and possible substances onboard. As for overwhelming force, we had 4 EMTs and 4 police officers. The patient was handcuffed when we started. And we were all panting when it was over. Not how I wanted it to go, but nobody asked me.

  43. I'm not even a little bit convinced by your argument Ben. First, I've been in EMS for 30 years, I've done a lot of CPR in that time, so I know how tiring it is. Still, in my system we manage to do a lot of cardiac arrest calls with three fire fighters (the driver stays with the engine) and at most two EMTs and two paramedics. Our save rate is right up there with the best systems in the country. This is going to be a long reply and rather than tie up Mark's comments section with it, I'm going to reply on my blog. I'll refer back to this post and the comments, but it's better for a number of reasons for me to post my reply over there.

  44. I'd like to see some evidence for your claim, and your definition of whom “the best systems in the country” are. And, if you don't responde to fires in San Fransisco, then your comments about their system are moot.

  45. May I please wish you, your family and the team over here and USA a fantastic xmas and all the best for 2010 lv joan and family from the midlands xxx

  46. May I please wish you, your family and the team over here and USA a fantastic xmas and all the best for 2010 lv joan and family from the midlands xxx

  47. Ad Hominem Abusive

  48. The last thing we need is more ambulances, we need less patients. I will be the first to tell you the 2 engine dispatch model is a waste of resources. No other way to describe it but waste. We do have a large number of fire resources deployed for the reasons mentioned in these comments and it made sense to use those resources to respond to the increase in EMS demand over the last 15 years. Adding more ambulances, even if we decrease the number of engines to staff them, will still not benefit the patients who have to wait because we're taking someone who doesn't need an ambulance to the hospital. These folks I call clients. they have no chief complaint, illness or injury that fits my protocols or can be helped by an ambulance, but demand transport.I am in the process of developing a solution to this issue, but it will take time and political support to put it in place. We need 40-44 engines and 15-20 trucks to cover our mostly 100 year old wooden city with most buildings less than 1/8″ apart. For now they double dispatch because of the requirement to have 2 paramedics respond to each “emergency.” If we simply had more ambulances, we would be sending 2 ambulances to each run. Another waste.In the end, a proactive system that puts the needs of the patient ahead of the demands of the client will take the heavy load off of 2 of the nation's busiest engines and let fire engines fight fires, deal with haz-mat, rescue and assist when medics need them.I'm working on it.

  49. Where I work, our typical crew response on a resuscitation is 4 people – 2 medics and 2 EMTs. Our survival rate is around 20% survival to hospital discharge, whereas SFFD's is what, 22%? Our survival rate has increased dramatically in the past 5 years due to one thing: increased focus on BLS. More paramedics do not make a better resuscitation.And who says 8, 10 or more people on a code team makes perfect sense? In my experience, about 5 of those people are standing around doing nothing.

  50. Your response model is a “problem?”Perhaps not, if you've got the tax money and resources to fund it.Still, other systems manage to accomplish the same thing with 1/3 the resources and apparatus. I think that's the point CBEMT was trying to make.

  51. As to the original comment, just because an all-BLS crew can manage an OD doesn't make that the ideal way to do it.True. But that doesn't mean that 11 personnel and 3-4 apparatus on a scene is the best way to do it, either.There is a middle ground.Not pointing any fingers at SFFD nor any service in particular, but the approach in many fire/EMS systems seems to be how many personnel can you justify for one response, versus how many are actually necessary.

  52. Or SFFD could “tier” their system so that there are ALS and BLS ambulances. Use a triage system that prioritizes and dispatches BLS only on none critical cases and some combination of engine/ALS/BLS on more critical cases. It's worked well in other cities, it's just not a model most FDs are comfortable with. Miami-Dade Fire recently started adding “squads” which are BLS ambulances staffed by FFs. In the past, they referred BLS calls to private services, mostly AMR, but only after an ALS unit of some sort did the assessment. One of the things that makes EMS in the US so difficult to pigeon hole is the fact that there are 50 or so models of EMS delivery. Which should keep Mark busy visiting us all!

  53. Sounds like the quickest way to eliminate some of the overkill is to eliminate the “2 medics on EVERYTHING don't care how you get em there” rule.

  54. I don't think that 11 personnel and 3-4 apparatus for a single patient is the norm for SFFD, but for Delta-priority calls where a life may be at stake I'd rather ensure that enough help is there quickly than to just hope enough is there.

  55. That's not even argument, it's boilerplate. So far, chief, you haven't advanced one bit of evidence to support your statements. I would think a chief officer with your experience could do better.

  56. Tim, asking for evidence to back a claim is not either ad hominem or abusive.Asking for a definition of a nebulous, generic claim is neither ad hominem or abusive, either.And, for anyone who doesn't work in San Fransisco, comments are indeed moot, because that person doesn't get to design their system, which is neither ad hominem nor abusive, it's just the simple fact.”Ad hominem” and “abusive” are applicable, however, to someone who has demonstrated very little knowledge of either San Fransisco or their fire/EMS department and yet posts repetitive attacks on their system.

  57. A.D., using a different response model due to different local circumstances doesn't make that model choice “a problem”, no matter what another model in another place may accomplish.If your model doesn't include fire protection for a city with numerous buildings from circa 1907 residing on a major fault line, and using ALS engine companies to keep more ALS resources available with the same amount of manpower, then I'd submit that it's an apples and oranges comparison.Local geography, hazards, and demographics are variables that don't necessarily mean that a model that's successful in one place will be successful in another.

  58. A.D., resuscitation survival rates are only a small part of overall EMS system desirable outcomes, although they are important. There are a lot of other factors including response times, call volumes, geography, demographics, what's allowed by state law and local medical directors, citizen CPR programs and citizen CPR participation that affect resuscitation survival rates. Also, one Utstein save has more statistical impact upon a small, slow system's outcomes than a big, busy one like S.F. I don't know where you work, but if you work in a smaller, slower system, that could be a factor in the 2% (or whatever it is) difference in those stats.

  59. What??? As opposed to the lack of evidence that exists for under-responding???What the evidence shows is that CPR and the 1st defibrillation are the most important things for Utstein survival. If a BLS engine company can do both and also has the manpower to keep the scene safe from traffic (engine as a traffic blocker), carry the patient and equipment, and an ALS ambulance has a reasonable response time (no evidence yet to support what that time might be) then an ALS non-transport unit might not be needed. Then again, with the large number of non-Utstein resuscitations that should probably be field DOAs, there's not a lot of evidence to support transporting those patients at all unless it's one of the less than 1% that has field ROSC.And…I haven't seen you show any evidence to support your stand, either, so what we're talking about is doing the best we can in the absence of evidence. Said evidence will be a long time coming, particularly with the apples-to-oranges (and strawberries, and bananas, and pears, and kiwi fruit, and watermelon, and…etc) EMS delivery models that exist.There's no evidence that what works in one place will work everywhere, either.

  60. Sounds like the quickest way to eliminate some of the overkill is to eliminate the “2 medics on EVERYTHING don't care how you get em there” rule.

  61. I don't think that 11 personnel and 3-4 apparatus for a single patient is the norm for SFFD, but for Delta-priority calls where a life may be at stake I'd rather ensure that enough help is there quickly than to just hope enough is there.

  62. That's not even argument, it's boilerplate. So far, chief, you haven't advanced one bit of evidence to support your statements. I would think a chief officer with your experience could do better.

  63. Tim, asking for evidence to back a claim is not either ad hominem or abusive.Asking for a definition of a nebulous, generic claim is neither ad hominem or abusive, either.And, for anyone who doesn't work in San Fransisco, comments are indeed moot, because that person doesn't get to design their system, which is neither ad hominem nor abusive, it's just the simple fact.”Ad hominem” and “abusive” are applicable, however, to someone who has demonstrated very little knowledge of either San Fransisco or their fire/EMS department and yet posts repetitive attacks on their system.

  64. A.D., using a different response model due to different local circumstances doesn't make that model choice “a problem”, no matter what another model in another place may accomplish.If your model doesn't include fire protection for a city with numerous buildings from circa 1907 residing on a major fault line, and using ALS engine companies to keep more ALS resources available with the same amount of manpower, then I'd submit that it's an apples and oranges comparison.Local geography, hazards, and demographics are variables that don't necessarily mean that a model that's successful in one place will be successful in another.

  65. A.D., resuscitation survival rates are only a small part of overall EMS system desirable outcomes, although they are important. There are a lot of other factors including response times, call volumes, geography, demographics, what's allowed by state law and local medical directors, citizen CPR programs and citizen CPR participation that affect resuscitation survival rates. Also, one Utstein save has more statistical impact upon a small, slow system's outcomes than a big, busy one like S.F. I don't know where you work, but if you work in a smaller, slower system, that could be a factor in the 2% (or whatever it is) difference in those stats.

  66. What??? As opposed to the lack of evidence that exists for under-responding???What the evidence shows is that CPR and the 1st defibrillation are the most important things for Utstein survival. If a BLS engine company can do both and also has the manpower to keep the scene safe from traffic (engine as a traffic blocker), carry the patient and equipment, and an ALS ambulance has a reasonable response time (no evidence yet to support what that time might be) then an ALS non-transport unit might not be needed. Then again, with the large number of non-Utstein resuscitations that should probably be field DOAs, there's not a lot of evidence to support transporting those patients at all unless it's one of the less than 1% that has field ROSC.And…I haven't seen you show any evidence to support your stand, either, so what we're talking about is doing the best we can in the absence of evidence. Said evidence will be a long time coming, particularly with the apples-to-oranges (and strawberries, and bananas, and pears, and kiwi fruit, and watermelon, and…etc) EMS delivery models that exist.There's no evidence that what works in one place will work everywhere, either.

  67. That I understand, Ben, and I don't discount SFFD's fire suppression challenges. And I suppose that, if keeping that many crews/apparatus/resources on line 24/7 is considered necessary, it makes fiscal sense to put them to work doing other things when they're not fighting fires.Still, I'm not convinced it actually is efficient, nor that one can do both fire suppression and EMS at the same time and master both.Adequate, certainly. Proficient, possibly.But I seriously doubt that mastery of both is possible.But that's an entirely different kettle of fish, and one filled with political considerations I have to taste for addressing.Shame that what we do so often is political window dressing, and inefficiently sewn window dressing at that.

  68. Darned Disqus system has no spell checker. That should have read “NO taste to address.” 😉

  69. When you said …”I'm not sure what evidence you think I haven't provided, but while on the subject you haven't provided one bit of evidence (better outcomes) by having a lot of fire fighters standing around at a scene. You're just sort of thrashing around looking for excuses to send more fire fighters to clutter of medical scenes.”…I haven't advocated anywhere for having firefighters “clutter” a medical scene, nor have I advocated for having unused responders stand around. I'd appreciate it if you wouldn't put words in my mouth and would confine your responses to things I've actually said instead of interjecting straw men into the discussion. I have listed several advantages that can result from having adequate manpower to lift and carry the patient, block traffic, andmaintain patient privacy, none of which can be measured in the clinical outcomes you apparently want to restrict the conversation to, but which can clearly be measured in terms of responder safety and health and patient satisfaction – things that my system measures and that hospitals measure, but which most EMS systems apparently do not.As previously stated, in a combination fire/EMS system, there are non-EMS considerations to the crew configuration and size, and to response vehicle types. When viewed with EMS-only blinders on, those may not be considered pertinent. For those systems that run EMS in a model that includes other services, those issues are very pertinent, as the crew integrity is important, regardless of the type of call.

  70. Why would we want to block traffic in front of someone's house? Most of the time we can carry our own equipment, carry the patient, and do all the other things you say that a BLS company can do. What large number of non Utstein resuscitations? If you don't track them, how do you know that they exist. Or do you mean resuscitation attempts? If that's what you mean, then you're correct and in our system we DON'T transport patients that don't have ROSC most of the time. Which again has no bearing on whether using 11 people at a call is overkill. You'll also notice that Justin says that their model is far less than ideal. Response time is a terrible measure of EMS systems, since most calls aren't time sensitive. Again, that's a political issue since no one has ever measured response times in relation to outcomes. Which, BTW, is what medicine is all about outcomes. Which is why cardiac arrest survival is used as a measure of EMS systems. It too is a terrible measure of EMS systems, but it's easily quantifiable. Patients either are either dead or alive. I'm not sure what evidence you think I haven't provided, but while on the subject you haven't provided one bit of evidence (better outcomes) by having a lot of fire fighters standing around at a scene. You're just sort of thrashing around looking for excuses to send more fire fighters to clutter of medical scenes.

  71. When you said …”I'm not sure what evidence you think I haven't provided, but while on the subject you haven't provided one bit of evidence (better outcomes) by having a lot of fire fighters standing around at a scene. You're just sort of thrashing around looking for excuses to send more fire fighters to clutter of medical scenes.”…I haven't advocated anywhere for having firefighters “clutter” a medical scene, nor have I advocated for having unused responders stand around. I'd appreciate it if you wouldn't put words in my mouth and would confine your responses to things I've actually said instead of interjecting straw men into the discussion. I have listed several advantages that can result from having adequate manpower to lift and carry the patient, block traffic, andmaintain patient privacy, none of which can be measured in the clinical outcomes you apparently want to restrict the conversation to, but which can clearly be measured in terms of responder safety and health and patient satisfaction – things that my system measures and that hospitals measure, but which most EMS systems apparently do not.As previously stated, in a combination fire/EMS system, there are non-EMS considerations to the crew configuration and size, and to response vehicle types. When viewed with EMS-only blinders on, those may not be considered pertinent. For those systems that run EMS in a model that includes other services, those issues are very pertinent, as the crew integrity is important, regardless of the type of call.

  72. In therein proves my argument. Combination departments by and large, consider EMS just one more thing that they do. EMS only systems are built around patient care. Which is probably why they tend to have better resuscitation rates, and don't tend to have things like the several recent incidents in Washington, DC. Plus they are way more cost efficient than combination departments.

  73. totwtytr, It proves nothing of the sort. Many EMS-only systems are built around patient transport and billing, not patient care.Many of the ones that do focus on patient care force their employees to take ridiculous risks in the interests of “cost efficiency”. If you want to discuss the best resuscitation rates, let's look at a couple of really good ones – Seattle Fire Department, the standard by which resuscitation is judged, and Miami-Dade, which is a completely different model, completely different geography and demographics, and both are committed to patient care. EMS departments are not, repeat not necessarily more cost efficient than combination departments. As an example, Phoenix FD won the right to run EMS due to pointing out all of the hidden costs in an EMS model; costs that were borne by the FD regardless of who ran the transport component. Another example is my department. We provide twice as many ambulances as the former split system with a 40% reduction in costs compared to what it would take to run the old split system. We also are the only EMS system in our state that participates in the CARES registry, and we issue customer satisfaction surveys to every patient. Our surveys, incidentally, consistently run in the high 90% for “satisfied” or “very satisfied” responses for the overall experience. Then let's talk about the traditional EMS complaints – disposable work force, low pay, poor benefits, no career ladder. Very few FD/EMS systems have those complaints because on the whole they have better pay and benefits, a career ladder, non-ambulance career path options for a much higher percentage of the work force, and the possibility of actually retiring instead of switching careers or being forced off the job due to a back injury from carrying patients down 4 flights of stairs – or up 1 flight – several times a day with that “cost efficient” two-provider, one patient model.As for D.C., they had tons of similar incidents when they had a seperate EMS department. I know from personal experience – I started my career in a D.C. suburb and am very familiar with their systems, old and new. I worked with two of their former medics after they left, citing the terrible working conditions, uncertified personnel still actively working the street, and a host of problems similar to the ones that have made recent news. D.C.'s problems are way bigger than the system model, and the system model now actually has fewer problems than 10 or 15 years ago, due to – gasp – the firefighter EMTs that staff the BLS ambulances without compromising BLS response but increasing ALS availability. D.C has also had some high-profile sucesses – the recent Metro accident/MCI comes to mind. The interoperability and built-in unity of command that FD/EMS systems have is a huge advantage in large incidents.Several of the most successful non-fire EMS systems are 3rd services organized very much like a fire department. Austin-Travis County Texas, Pittsburgh, Guilford County, NC, and Wake County, NC come to mind. Things they have in common – they operate some non-transport vehicles including Pittsburgh's EMS Heavy Rescues and Wake County's APP chase cars. SFFD's analog to Wake County's chase cars – the Rescue Captain's SUVs. There are also a lot of variables that contribute to resuscitation statistics that are completely out of control of the system, regardless of the model. Singling out a single one of those variables as the supposed culprit can't be proven without a comporehensive, multivariate infinite regression study, and a single correlation might not be proven even with those studies, which don't exist.

  74. AD, I don't claim to have mastered both EMS and Fire, but can one not be proficient as a lawyer and still spout baseball facts and statistics at the drop of a hat? Or an accomplished dancer be a master computer code writer? Just because we've lumped these two things, fire and ems together doesn't mean you have to pick one. Are you less of a gun enthusiast because you are also a Paramedic?And does one need to truly master something to be passionate and proficient? I say no. My downtime from fires is learning to be a better Paramedic. My downtime from being a Paramedic is learning to be a better firefighter.I can do both while you can do one. That is what I do. I am not better, just different.

  75. So long as by analog you mean outdated. the Rescue Captain role is grossly UNDERutilized in the community, mainly to screen out sick calls from emergency calls, something I am hoping the system will flex to allow. This discussion has indeed taken a remarkable turn and fallen into the white shirt blue shirt debate that has raged for almost 50 years now and will continue long after I hang up my coat. I do have to hand it to the commentators here, although heated, they remain civil. Let's keep that dialogue open!

  76. I nearly blew his mind describing the dozen or so models just in the Bay Area! Indeed the SFFD did a BLS tier trial run and staffed them with firefighters who didn't want to be there. Result: Too many over triaged calls going ALS anyways. Huh, who saw that coming? Then supervisors mirco-managing the system to the point of collapse. It was a HUGE deal when they broke out of the Paramedic driver role and staffed an EMT and Paramedic. I always thought getting people who want to be there would be an excellent idea and half our fleet could be BLS, realistically, but we'd need to keep the ALS first response in that case, otherwise we're stacking a BLS transport unit onto a BLS first response. But if I can use things I learned in England to design a kind of RRC program to augment the ALS resources deployed, I can free up 6-8 engine companies from their ALS duties, serving as their medic in a kind of “2 piece engine company” at first, then as a stand alone resource. We have the resources staffed and deployed, the response model needs to be adjusted.If I can get it working the way I think it can, Mark's OD call that started all this would have had 1 medic in a car, an EMT and Medic in the ambulance and an engine available should the patient become combative or should they need the man power.And in the rare event of a critical patient we can grab an EMT and I can lock the car and go in with the ambulance. 2 medics and an EMT in the back is many a system's dream from what I'm reading online.Thank you everyone for showing such passion about what we do! Hey Mark, look what you started!

  77. I'd love that, but with so many of our brothers and sisters making glaring stupid mistakes, that rule is likely to remain for awhile. The trick is figuring how to get that second medic enroute without taxing the system.

  78. TOTWTYTR is from Boston, Chief. So his claim to be from “one of the best EMS systems in the country” is valid, at least in my opinion. Interesting discussion, though. One of the most civil Fire/EMS discussions I've seen in a while (although that's probably not saying much). I think I'm one of the few who sees both sides of it. I think it is more difficult for fire-based EMS to be proficient. But I've seen enough 3rd service EMS systems that suck to realize the truth is complicated.

  79. Ben, you are singularly unconvincing. Phoenix isn't ground breaking, and frankly since Brunacini retired we haven't seen a thing from them. Has anyone done a recent analysis to see if the cost savings are real? For that matter has anyone done one for YOUR system? We make money and have wage and benefits better than most of the FDs around us. I've been to Miami – Dade, great, friendly, guys, but they are definitely not cutting edge. That DC is BETTER now that they are part of the fire department, doesn't mean that they are good, or even acceptable. That system is a exemplar of how not to run any EMS system. As I've said before, you use a stop watch to measure the tenure of their medical director, not a calendar. Tulsa FD is in the middle of a cheating scandal for paramedic certifications. A few years ago Lincoln, NE won the EMS system based on their claims that it would be cheaper, faster, better, but it turned out not to be. FDNY used the same claims in 1996, has anyone done an audit to check on their claims since. Speaking of audits, did you ever read the Civil Grand Jury report on SFFD EMS? Or the comptrollers report? I did, as I also read “The Main Line” and the minutes of the Fire Commission meetings, including the one where they decided to abandon the dual role firefighter model a few years ago. Fire EMS can work, and it does in some smaller systems. So far it hasn't proven that it can work in large cities, with entrenched fire departments. In systems such as DC, LA City FD, and Chicago, the medical director has no power to decide who can be a paramedic and who can't. We can go back and forth for months, but I'm not going to. The numbers show that fire EMS in big cities just doesn't work as well as non fire EMS. All of the fire departments in the country, along with the IAFF and IAFC, sticking their fingers in their collective ears and saying “LA, LA, LA, LA, I can't hear you.” isn't going to change it. When fire departments start treating their EMS components as equal to the suppression side, give command authority to medical directors, stop using EMS as the “new guy” assignment, or worse as punishment duty, then come back and we'll chat. Until then, it's just the same old fire service song.

  80. And of course I did forget perhaps my most important observation. To have fire department first response that effects outcomes, you need the fire department to be first responders with CPR and AEDs. That DOES NOT mean that the fire department has to or should run EMS. As I noted, Hennepin County uses a lot of police first response. I think Nassau County (police operated) EMS does as well.

  81. Too many hours, I reread you comment “proficient,possibly” I misread the first few times.

  82. totwtytr,Re: your Phoenix/Brunacini comment; If every EMS system has to be cutting edge 24/7/365, to be considered effective, then there are virtually no effective EMS systems anywhere, regardless of the system model.The issues with large cities that you blame on the FD/EMS model are not necessarily the fault of the EMS system. For every Boston EMS, we have a Seattle FD/EMS. There are also plenty examples of non FD/EMS systems in large cities with mega problems, including constant employee turnover, like the hospital-based system in Atlanta, or the private transport systems in Mobile, Birmingham, and Montgomery, Alabama that have all been taken over and improved by the Fire Department.You allege that the common denominator for these problems is the FD management, but there's no evidence to suggest that this is the case, given the non-fire examples that have similar problems.D.C.'s problems now are actually not as bad as when EMS was seperate a few years ago. They have more BLS transport units available, and they rotate the personnel on those units. Their medical director issue predate the fire/EMS consolidation by many years. They are not the only EMS system with medical director issues, and a lot of those systems are not FD/EMS systems. Austin/Travis County, TX has one of the best non-FD EMS systems in the country, and their medical director recently left their system. That doesn't make it the system model's fault. D.C. is a special case – they are funded differently than any other EMS system, they have a unique set of politics, and they couldn't maintain a functional seperate EMS system when they had one.As for ambulances being a new guy assignment, where does your system put the new guys?Re: my system, we do a monthly cost-benefit analysis that is reported to our mayor and council. They are very happy with the current system that includes being the only CARES registry system in our state, despite the majority of EMS systems here being non-fire. We use a cross-staffing model that results in every line employee below the rank of Battalion Chief maintaining EMT or Paramedic certification (both state and national registry) as a condition of employment. Our model also results in every employee working both and engine and an ambulance, usually a mix of both during every shift. The only exception is a single truck/rescue unit whose personnel rotate to the engine/ambulance assignment, but less frequently than every day. There is no seperation between fire and EMS for us, so there's no “new guy” or “punishment” assignment to an ambulance.That begs another question – where do non-FD EMS systems (including yours) put their employees for a punishment assignment?. I've worked several non-fire EMS systems. The two best in terms of productivity, clinical care, response times, and community and patient satisfaction were the two FD/EMS ones. Does your system survey 100% of its patient for customer satisfaction? If not, why not? Customer satisfaction is every bit as important to an EMS system as Utstein survival rates, response times, etc. After all, customer satisfaction is an outcome, as any hospital administrator can tell you.When you insist that a single variable (the FD management) is the reason for problems in a large-city FD/EMS system despite the obvious multiple variables involved, that's also the equivalent of sticking fingers in the auditory canals and saying “LA, LA, LA, LA, I can't hear you”. When non-fire EMS globally has non-disposable employees, pays actual living wages, has a real career ladder, has a decent pension/retirement system, and understands that EMS is more than just riding an ambulance to the next job, then we'll chat. Until then, it's just the same old non-fire EMS song.

  83. TOTWTYTR – I personally think that police and fire should both be CPR/AED equipped, whether they run the EMS system or not. But you raise a good point. In the vast majority of cases, third-service EMS can't do it by themselves. That doesn't necessarily mean that police or fire should take over EMS, but it does make EMS a bit different. Tom

  84. Anybody can get positive satisfaction surveys by being nice to the patient. I'm not impressed. Are the patients actually getting the care they deserve from a provider capable of giving it? The patient doesn't know whether or not the care they received was competent and correct, they just know they got taken to the hospital and aren't dead. There's a big difference between that and quality. Using Seattle as a positive Fire-EMS example is like comparing apples and carrots-Paramedic as a PROMOTION from Suppression.-Same physician-run, nationally accredited Paramedic school for all candidates, regardless of previous education, with more didactic and clinical exposure than any other program in the country, from what I can tell.-Paramedics provide critiques on first-response fire crews to management-Both FD and private BLS transports-No other ALS-licensed agencies allowed to operate in the city/county.But yeah. They're just like a lot of other FD-EMS systems. Please. If you could show a Seattle (which, as we can see, barely counts as a standard FD-EMS system anyway) for every Boston EMS out there, you'd do it. But you can't.

  85. TOTWTYTR – I personally think that police and fire should both be CPR/AED equipped, whether they run the EMS system or not. But you raise a good point. In the vast majority of cases, third-service EMS can't do it by themselves. That doesn't necessarily mean that police or fire should take over EMS, but it does make EMS a bit different. Tom

  86. Anybody can get positive satisfaction surveys by being nice to the patient. I'm not impressed. Are the patients actually getting the care they deserve from a provider capable of giving it? The patient doesn't know whether or not the care they received was competent and correct, they just know they got taken to the hospital and aren't dead. There's a big difference between that and quality. Using Seattle as a positive Fire-EMS example is like comparing apples and carrots-Paramedic as a PROMOTION from Suppression.-Same physician-run, nationally accredited Paramedic school for all candidates, regardless of previous education, with more didactic and clinical exposure than any other program in the country, from what I can tell.-Paramedics provide critiques on first-response fire crews to management-Both FD and private BLS transports-No other ALS-licensed agencies allowed to operate in the city/county.But yeah. They're just like a lot of other FD-EMS systems. Please. If you could show a Seattle (which, as we can see, barely counts as a standard FD-EMS system anyway) for every Boston EMS out there, you'd do it. But you can't.

  87. For every Seattle, there are large FD/EMS systems that don't perform as well and that have demographic and economic problems that are much greater than Seattle's.For every Boston EMS, there is an Atlanta or a Cleveland.

  88. For every Seattle, there are large FD/EMS systems that don't perform as well and that have demographic and economic problems that are much greater than Seattle's.For every Boston EMS, there is an Atlanta or a Cleveland.

  89. For every Seattle, there are large FD/EMS systems that don't perform as well and that have demographic and economic problems that are much greater than Seattle's.For every Boston EMS, there is an Atlanta or a Cleveland.

  90. Excellent! Great article, I already saved it to my favourite,

  91. Thanks for information, I’ll always keep updated here!


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